Page 33 - Cover letter and evaluation for Peter Smith
P. 33
11/27/2017 Your Medicare Health Plan Details
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Prescription drug
Your Plan Details coverage. Estimated
annual costs include
Zip Code: 89129
premiums, Current Coverage: Original Medicare
deductible, and co- Current Subsidy: No Extra Help [?]
Select the tabs below for more detailed information about the plan health benefits, drug costs Drug List ID: 2579428096
and more coverage and star ratings. payments.
Password Date: 11/23/2017
Important Coverage Information
You are now viewing 2018 plan data. View 2017 plan data.
Symbols
A process through which the physician or other health care provider is required to obtain advance approval from the plan that payment
will be made for a service or item furnished to an enrollee. Unless specified otherwise with respect to a particular item or service, the
enrollee is not responsible for obtaining (prior) authorization.
A process through which the enrollee’s primary care physician or other network physician (depending on the plan policy) permits or
instructs the enrollee to obtain an item or service from another physician or other provider type.
Some Dental Coverage Some Vision Coverage Some Hearing Coverage
* Estimated
Anthem Value Plus (HMO) 12900 Park Plaza Drive, Suite Overall Star Rating: [?] Enroll
150
(H4346-001-0) Cerritos, CA 90703
3.5 out of 5 stars
Organization: Anthem Blue Cross and Members:
Blue Shield 1-800-499-2793
711 (TTY/TDD)
Plan Type:
Non Members:
1-844-309-6995
711 (TTY/TDD)
Fixed Costs
Monthly Drug Plan Premium [?] $0.00
Monthly Health Plan Premium [?] $0.00
Annual Drug Deductible [?] $0.00
Medicare costs at a glance
Estimate of What YOU Will Pay for Drug Plan Premium and Drug Costs
Full Year Cost (based on January enrollment) [?]
Walgreens #04197 $3,071.27
CVS Pharmacy $3,009.40
Mail Order Pharmacy $2,840.03
Full Year Cost (based on January enrollment) [?]
https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H4346&plnid=001&sgmntid=0#plan_drug_cost 1/4
